Advance Access: Awake Craniotomy vs Craniotomy Under General Anesthesia for Perirolandic Gliomas: Evaluating Perioperative Complications and Extent of Resection

Maximal surgical resection in patients with a hemispheric glioma has been shown to have a positive effect on progression-free and overall survival.1-10 For gliomas located in eloquent regions of the cortex, a balance must be reached that maximizes tumor resection, but avoids the surrounding functional tissue.11 This feat is made more difficult since evidence has shown that the traditional idea of debulking a tumor from within in order to avoid new neurological deficits may not be applicable for high- and low-grade gliomas, which have been reported to also contain functional tissue.12,13

An awake craniotomy (AC) for surgical mapping of the sensorimotor and language function presented an approach that could be used to try to enhance safety and maximize the extent of resection of tumors in eloquent regions of the brain.1,14,15 By directly stimulating the cortical and subcortical areas that are in proximity of the tumor, an AC allows for identification of functionally relevant areas of the brain that require preservation.6 This technique has enabled tumor removal from highly functional eloquent regions that were once considered inoperable.16

Prior studies have shown that intraoperative awake mapping reduced postoperative morbidities, improved neurological outcomes, and had a better extent of resection compared to similar surgery done under general anesthesia (GA), but the majority of tumors in these studies were located in the cortical speech area.6,17-20 Many surgeons limit the use of an AC to lesions found within the language cortex, as some studies have suggested that awake resections of perirolandic lesions, involving the precentral gyrus, have a higher incidence of intraoperative seizures.1,21,22 Overall, only 22% of glioma resections use ACs for mapping.23 This likely results from the complexity of the procedure and failure rates, which can result from poor patient selection and inadequate intraoperative anesthesia.16,20,22

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